Author: Nancy Melville
Although guidelines designed to address the overprescription of opioids have succeeded in lowering the number of prescriptions, reports of unsatisfactory postsurgical pain control have increased, according to a study presented at the 2020 Virtual Meeting of the American College of Surgeons (ACS).
“Evidence-based opioid prescribing guidelines successfully reduced opioid prescribing without increased refill rates,” said Cornelius A. Thiels, MD, Memorial Sloan Kettering Cancer Center, New York, New York. “However, there remains a subset of patients whose pain may not be optimally managed within these guidelines.”
In a previous study, Dr. Thiels and colleagues estimated that up to 62% of opioids prescribed after surgeries went unused, which comes to >1 million tablets per institution per year.
As a result of these findings, evidence-based prescribing guidelines were developed by the Mayo Clinic, Rochester, Minnesota, where Dr. Theils received surgical training.
To evaluate the effects of the protocol, the researchers analysed data from patients who underwent elective general surgery and were surveyed a median of 26 days after discharge from the Mayo Clinic before and after implementation of the guidelines. All patients were opioid naive before their procedures.
Of the patients, 603 underwent procedures before implementation of the prescribing guidelines and 138 had procedures after. No significant differences were seen between the groups in terms of age, sex, race, and diagnosis of anxiety, or depression.
Before the guidelines, patients used opioids for a median of 3.0 days post-surgery (interquartile range [IQR], 0-7 days). Interestingly, the time patients used opioids increased to 4.0 days (IQR, 2-7 days) in the group treated after implementation of the guidelines (P = .007). However, no significant increase was seen in the number of refills, noted Dr. Thiels.
Patient-reported pain control after discharge was better before versus after implementation of the guidelines (9 vs 8 [scale of 0-10, lower score representing worse pain control]; P = .002).
Although most patients in both periods reported being very or somewhat satisfied with their pain control (93.3% before guidelines vs 87.7% after guidelines), significantly more patients reported being very or somewhat dissatisfied with their pain control after the new guidelines (4.2% vs 9.4%; P = .04).
The rate of patients indicating that they were not prescribed enough medication at discharge increased from 4.9% to 12.5% post-guidelines (P = .002). However, the rate of patients in this group who indicated that they were prescribed too much medication at discharge decreased from 33.8% to 20.8% (P = .002).
Newer postsurgical pain management guidelines suggest a multimodal pain-control approach that combines use of opioids and nonopioid pain relievers. The goal is to “give [patients] the exact right amount so that we limit the number of unused opioids in our community while also making sure we don’t reduce it down too far and then leave them in pain,” said Dr. Thiels.
He noted that with more operations taking place in outpatient settings, careful management of pain is even more important.
“People are going home sooner and sooner, and that’s great, but we need to make sure their pain is well controlled after they leave the hospital, as well as balancing that issue with the risk of opioid dependence,” said Dr. Thiels.
The next step is to determine how to best identify patients who may have lower pain scores after discharge with the reduced opioid prescribing guidelines, he noted.
“The right answer may be more nonopioid-based pain medications, better patient education, and setting of expectations; or in some cases, patients may actually require slightly more opioid medications, and that is okay — everybody should have their pain appropriately controlled after surgery,” said Dr. Thiels.